S1764 Localized Truncal Xanthoderma Secondary to Bile Leakage Post Laparoscopic Cholecystectomy

Abstract

Introduction: Xanthoderma is a yellow to yellow-orange discoloration of the skin. The 2 main pathologies leading to xanthoderma are jaundice and carotenoderma. Although the most common mechanism for jaundice is the elevation of serum bilirubin, localized jaundice can rarely occur in the settings of bile leakage into the retroperitoneal space. Case Description/Methods: A 40-year-old female patient presented with biliary pain. Examination showed right upper quadrant tenderness. Initial labs revealed total bilirubin of 49 µmol/L, with a direct bilirubin of 47µmol/L (Table). The US abdomen showed cholelithiasis. MRCP showed a small distal CBD stone; CBD diameter was 9 mm. She underwent laparoscopic cholecystectomy with an intraoperative cholangiogram. The small distal CBD stone was pushed to the duodenum. Repeated IOC showed a smooth passage of contrast. Her clinical status didn’t improve postoperatively, and her bilirubin was persistently elevated. Localized yellowish discoloration of the right side of the abdominal wall and the suprapubic area was observed 5 days after the surgery (Figure A). Repeated MRCP showed suspicious distal CBD stone with gall bladder bed collection and diffuse inflammatory change of the right abdominal wall. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a bile leak at the site of the cystic stump (Figure A) and a small filling defect in the distal CBD. Sphincterotomy and CBD stenting were performed. The bilirubin improved gradually after ERCP, but the abdominal pain persisted. CT abdomen showed large perihepatic and perisplenic fluid collection measuring 10x 17.6x 20 cm, necessitating US-guided percutaneous drainage. Turbid yellow fluid was drained, confirming that the collection was a biloma related to the bile leak. Four weeks later, the percutaneous drain was removed after the collection resolved. Repeated ERCP showed no biliary leak. Discussion: In our patient, the localized xanthoderma post laparoscopic cholecystectomy was secondary to bile leakage from the cystic duct stump. In a similar case report, the authors explained that the localized xanthoderma occurred as a result of bile staining of the tissues deep to the membranous layer of the superficial fascia (fascia of Scarpa) after the bile has leaked from the cystic duct through the hepatoduodenal ligament. The management of our patient involved sphincterotomy and bile duct stenting combined with percutaneous drainage of the collections.Figure 1.: A: Localized yellowish discoloration of the anterior abdominal wall. B: An ERCP fluoroscopic image showing contrast leakage near the cystic stump. Table 1. - Laboratory investigations Laboratory test Patient's value Normal range Total bilirubin 49 µmol/L 0-21 Direct bilirubin 47 µmol/L 0-9 AST 287 U/L 0-32 ALT 249 U/L 0-33 Alkaline phosphatase 264 U/L 35-104